COVID-19 vaccine wastage and distribution disparities in Pakistan: an editorial
Authors: Maham Zahid, Mehwish Naz, Hassan Mumtaz, Shahzad A. Khan
Journal: International Journal of Surgery (2023)

COVID-19, vaccination, and Pakistan Vaccination against coronavirus disease-2019 (COVID-19) remains a crucial defense and prevention to contain the spread and severity of this disease throughout the world. As of August 20, 2022, 598 million cases and 6.46 million deaths were reported globally. Among them, 1.57 million new infections and 30, 555 deaths were documented in Pakistan. Since the initiation of vaccination, till August 24, 2022, there have been 12.5 billion doses administered worldwide, allowing the complete vaccination of 67.59% of the population. In Pakistan, the total population is 230 million, where 291 million doses of COVID-19 vaccine have been administered, which makes 59.2% of the population fully vaccinated1. In the COVID-19 scenario, there are various driving factors that play an important role in ensuring global access to vaccines, starting from bulk production to meet global demand, affordability of the price that each country can pay, global allocation so that vaccines reach where needed most, and fair deployment to local peripheral communities. The World Health Organization in April 2020, created the COVID-19 Vaccine Global Access (COVAX) platform in collaboration with Coalition for epidemic preparedness innovations and global alliance for vaccines and immunisation (GAVI), for a pooled procurement initiative to secure low-priced vaccines for low-middle income countries and providing access to a diversified portfolio of multinational vaccines2. Equity and wastage issues Vaccine equity and vaccine wastage are both interrelated and two increasingly important public health concerns. The foremost prerequisite of health-for-all is equitable access to essential medicines and vaccines, which is a basic human right. Most of low- and middle-income countries were facing health system challenges long before emergence of COVID-19 pandemic, which further collapsed the fragile health system of many of such countries. Low- and middle-income countries face considerable difficulties in organizing their national health management system to prioritize, acquire, deploy, and deliver COVID-19 vaccines in respective countries. These countries, including Pakistan, lack the essential public health capabilities to guarantee basic health security. The incapability to strengthen the health systems infrastructure turns out to be the main reason for suboptimal vaccine coverage, vaccine equity, and wastage3. It is known that immunization programs have inevitable vaccine wastage, but it is recommended that the vaccine wastage be well monitored and efforts should be made to keep it to a minimum within the allowed range. According to the GAVI alliance, a maximum vaccine wastage rate of up to 25% is acceptable for the first year, with a reduction to a maximum of 15% wastage by the third year2. Vaccine wastage can occur at various steps of the whole vaccination process, from procurement to administration of doses. Sometimes vaccine wastage occurs when the vaccine vials are left open outside of required temperature, on the other hand, inability to fully use the vial for desired number of participants, temperature fluctuation during transportation and distribution, spillage of vaccine vials due to mishandling, and when the vaccine stock is left unused by its expiry date, can all lead to vaccine wastage. Vaccine wastage can also occur in developed countries where a sophisticated vaccine supply chain is in place, but wastage occur due to other associated factors. High rates of vaccine wastage have been reported in high-income countries such as France (30%) and Canada (25%)4. On the other hand, keeping in mind the ground realities of Pakistan, one can anticipate much higher wastage rates in the country, considering the inadequate supply chain management system. In Pakistan, the exact reporting of vaccine wastage rate is lacking, but according to media news reports, high rates of up to 30% have been reported3. Ways to overcome vaccine wastage For COVID-19 vaccines, there is already a shortage of vaccines in the world, the production is barely fulfilling the demand, it is important to focus on reducing the vaccine wastage especially due to avoidable causes. In a recent publication, Dor et al5. highlighted the issue of COVID-19 vaccine wastage in low-income countries and concluded that it is the responsibility of government to strengthen their national health programs to implement standard operating procedures to reduce wastage associated with vaccine transport, storage, and administration. Furthermore, strengthening the vaccination supply chain in terms of versatile information system, timely reporting, and monitoring of waste can play a substantial role in reducing wastage. Preventing the avoidable wastage of the COVID-19 vaccine in Pakistan is extremely important and challenging as it requires participation of multiple stakeholders to enhance process transparency, accountability, traceability, and data availability. Transparent data reporting of vaccine usage and wastage at all check points is important because it gives authentic realistic figures that are helpful in taking appropriate measures to prevent causes of vaccine wastage. The Pakistan supply chain management system needs to be improved to properly handle vaccines, maintain product integrity during transport and storage and deliver them safely before expiration6. In addition to supply chain management, there are several other effective strategies adopted by low- to middle-income countries to reduce vaccine wastage, including training health care managers and vaccinators to improve stock management, enhancing community mobilization, vaccine forecasting, and prioritizing wastage concerns. The first step to avoid vaccine wastage can be to report country data on vaccine wastage and identify its main causes based on which effective planning and decision making can be made. Local or nearby vaccine manufacturing has positively contributed to increasing vaccine availability and access. Local government and pharmaceutical manufacturers can put their efforts into prioritizing knowledge transfer, improving supply chain factors, and removing other potential barriers resulting in inequitable distribution and vaccine wastage7,8. Equitable distribution of COVID-19 vaccines The health care delivery system in Pakistan mainly consists of public and private sectors, where, as per the constitution, health primarily comes under government responsibility. The state provides health care through a three-tiered health care delivery system and a range of public health interventions including vaccination. To optimize the impact of vaccination, the equitable distribution of vaccines is the true call. This requires private–public partnerships at all levels of society to ensure equitable distribution of vaccines and minimize vaccine wastage. Previous literature shows that there exist significant socioeconomic and geographical disparities in access and distribution of routine vaccinations in Pakistan. For vaccines included in routine expanded vaccine program (expanded programme on immunization), disparities were reported between rural and urban areas, where 58% of the rural areas were fully vaccinated as compared to 85% vaccination rates in urban areas9. No specific data reported for rural and urban vaccination rates for COVID-19 vaccines, but it is likely that history would have repeated itself. In Pakistan, COVAX played an important role in assisting in the procurement of vaccines, by providing access to lower priced vaccines from different manufacturers in early phase of the pandemic, which also helped to launch the vaccination campaign that otherwise would not have possible. The existing expanded programme on immunization system in Pakistan is well established, through which routine vaccines are distributed to basic health units. This existing system supported the initial roll-out of COVID-19 vaccines in the country. Some vaccine storage facilities required modifications because the existing cold chain was not up to the par for some western manufactured vaccines like the Pfizer and Moderna, which demanded minus storage temperatures under ultracold chain conditions10. With the support of WHO, GAVI, and UNICEF, upgradation to the supply chain network concentrated at center and in metropolitan cities was made. However, the issue of vaccine delivery to local communities remained there, as it was dependent on the logistic and administrative challenges of the country. Equitable distribution of vaccines is under government's responsibility to allocate the required resources and prioritize distribution to neglected regions3,5,11. In addition to these factors, there come social and culture barriers which hinder the vaccination deployment process such as vaccine hesitancy. The literature reports that the hesitancy of the COVID-19 vaccine was quite prevalent in low-, middle-, and high-income countries alike, especially at the beginning of the pandemic, including diverse socioeconomic, ethnic, and religious groups, The vaccine hesitancy was reported to be highest in countries including Serbia (62%), France (56%), Paraguay (49%), Slovenia (47%), and Pakistan (44%). The three most frequently reported reasons for vaccine hesitancy in Pakistan were concerns about vaccine efficacy and safety; the general perception that vaccination does not work and religious/cultural reasons6,12. Conclusion Pakistan, like any other developing country in the world, is said to struggle to ensure equitable vaccine distribution while facing challenges of vaccine wastage. There is a need to develop a detailed and organized process to monitor and minimize vaccine wastage in Pakistan. Some mitigating strategies can include the identification of wastage rates and the main reasons for wastage, followed by properly organized donations, efficient handling of vaccine products, and strengthening the supply chain management system. The suggested strategies require the participation of multiple stakeholders including government, national and provincial health departments, public and private health centers to ensure transparent, traceable, auditable decentralized distribution of COVID-19 vaccines managed through a secure, reliable and trustworthy supply chain management system. Lastly, the national health program must use innovative communication methods to run an effective vaccination campaign, incorporating the local contextual factors associated with vaccine hesitancy to enhance acceptability and utilization of vaccines in local communities. At the same time, promote the beneficial effects of vaccination and encourage the healthy populations to make informed healthy choices. Ethical approval Not applicable. Sources of funding None. Author's contribution M.Z.: concept. M.N.: manuscript writing. S.A.K.: supervision. H.M.: editing and review. All authors have equally contributed to the manuscript and have approved the final manuscript to be published. Conflicts of interest disclosure The authors declare no competing interests. The views expressed in this article are those of the authors only and do not represent the views of the authors' affiliations. Research registration unique identifying number (UIN) None. Guarantor Hassan Mumtaz. Data statement Data will be made available upon request. Provenance and peer review Not commissioned, externally peer-reviewed. Availability of data and materials Data sharing does not apply to this article as no datasets were generated or analyzed for the current report.